Moving Upstream to Address Adverse Childhood Experiences in Missouri, Kansas

Adverse childhood experiences, or ACEs, may lead to poor outcomes later in life. When a child is shot or beaten, for instance, it increases the likelihood that he or she might develop substance-use or eating disorders in adulthood.

With that in mind, leaders in the Kansas City area have banded together to launch an initiative called Resilient KC, which has brought community members together to help battle childhood trauma and prevent those long-term health issues that can arise from such ACEs.

We recently spoke with Herb Kuhn, president and CEO of the Missouri Hospital Association, who along with his Kansas counterpart produced a report on possible ways that hospitals can intervene to help address ACEs. Kuhn talks about how he first became interested in ACEs and why he finds these data so alarming. He also offers advice for other hospital CEOs on how to begin implementing interventions in their service areas.

When did the issue of ACEs first catch your eye? What sparked you to take a closer look at this topic?

KUHN: So, what got us into ACEs was the fact that we, like everybody else, have been looking at various population health issues. But, as we watch the violence out there in communities and in hospitals and elsewhere, we continue to talk about the different things that we can do to take the conversation upstream further. And as we looked at the initiatives rolled out in Kansas City that’ve focused on ACEs, we thought maybe there’s a chance we can do a deeper dive on that for a couple of reasons. One is to help our members that were involved in the program there in Kansas City, but also help that project look at the ACE issues from a different, more data-driven process to help better identify where they can target resources. But the other part of the conversation, too, is something that we’ve been talking about here for a while: 2018 is when hospitals need to conduct community health needs assessments again. And, obviously, most community health needs assessments focus on two, three, four, maybe five disease-specific areas — diabetes, obesity, smoking, etc. We wanted to also say: Is there an opportunity to introduce a new concept for community health needs assessment? In addition to the disease-specific issues, is there a way that we can also have a conversation about specific ZIP codes in our area? What would a community health needs assessment look like if we were going that far upstream, dealing with some of the adversity issues that communities, and particularly children, are facing?

And the other thought behind that, too, is if we’ve brought in the ACE research and activity and conversation, it brings new community partners to the table. If you look at Resilient KC, they’ve got the police involved and a number of different law enforcement entities involved, and that intrigued us by the fact that you could bring different partners in by looking at geographic areas instead of disease-specific issues. This also might be an opportunity to bring in different churches, school districts, county governments, whatever the case may be.

The other thing that ACEs gave us was a chance to begin talking about the gun violence issue in a way that we haven’t been able to before. Any time you get into gun violence, it’s always the raw statistics. Well, we hope that by using ACEs it brings the conversation into the overall context of public health, toxic stress in the community, and it gave us a platform to talk about the issue in a less stressful situation, without all that other baggage attached to it.

I’ve heard you describe the data as “alarming.” Could you talk about why you were so taken aback by the findings?

KUHN: A couple of years ago, we did a research project for the Robert Wood Johnson Foundation. We got a grant and we were able to take a look at some of the county health rankings and created a new methodology that allowed us to do it by ZIP code. So we deployed that new ZIP code methodology into this, and I think the alarming thing that we found was two parts. One is how close in proximity some of these incidents can be in the Kansas City area, for example. What you found is places that were ZIP codes that were very close together, three, four miles apart or even closer, where you had such wide disparities — No. 1 in education, to very dead last in education, major food deserts — it gave us a mapping way of showing these things were occurring, even in close proximity. Yes, we all know we’ve got neighborhoods that are marginal on one side or the other, but it gave us incredible granularity on a number of factors out there, and that was alarming. The other thing that was interesting about it is it helped us really isolate the hotspots better than we’d ever seen before in terms of the alarming nature of where they were, and how large they could be when you get into some of the contiguous ZIP codes.

And then the third alarming part is the rural community nature of it. Everybody thinks a lot of this toxic stress is predominantly in urban neighborhoods. But we’ve found that it can be just as problematic in some of the rural areas. And I think particularly for two states like ours, which have both large urban and large rural areas, that gave us additional things to think about and gave our rural hospitals particularly a different way look at their communities and to engage on these issues.

Some of the ZIP codes mentioned in the report are in Illinois. Was there any talk of bringing that state, or others, into the fold as well?

KUHN: Well, we have a unique partnership with the Kansas folks, so we started there. But I think that would be something, as we go forward, to look at, more at East St. Louis and some of the opportunities in Illinois and other contiguous states. I will share with you that there’s been some federal agencies that have looked at the data and have actually invited us to come and do presentations at some of their meetings, particularly HRSA, the Health Resources and Services Administration. We did a presentation earlier this year at one of their meetings. So, there are others that are intrigued by this, and we’re continuing to branch out, looking for new partners to share ideas and best practices. Everyone has a story and we want to be able to make sure that we have the fullest way of showing those stories in different communities across the board.

Does this partnership with Kansas typify the way that hospital leaders need to be thinking in today’s health care environment, that you can’t just focus on one state or one service area?

KUHN: Yeah, I think so. I think that the nature of political subdivisions, whether they’re city, county or state borders, really make no sense. To give you a sense of Missouri, we border eight states. We have major metropolitan areas on our borders — Kansas City, St. Louis, Joplin, St. Joseph, Cape Girardeau — so it makes sense that health care markets look very different than political subdivisions. But the other thing, too, is, particularly in the Midwest, as more and more people have come together to recognize these issues and to use data in a more powerful way, I think it’s a way for us to not only look at the ACE issues, but also to look at those patients who are super utilizers in the system. That 5 percent of the population that uses 50 percent of the spend in health care. Some of them tend to be highly mobile and move around quite a bit. Likewise, when it comes to the opioid issue and prescription drug monitoring programs, you can’t expect these people to respect political subdivisions. They won’t. They’re going to shop all over the place. And I think, as more states continue to connect their [prescription drug monitoring programs], the more you can do this kind of interstate cooperation and build those relationships, one thing leads to another and it just serves the system better as we go forward.

What are some of the organizations you might look to partner with in the future to try and further this work related to adverse childhood events?

KUHN: We’re trying to engage government in different ways than we have in the past on some of these issues to help them think like we’ve been thinking about more upstream activities, instead of the here and now, dealing with this crisis. If you think of a medical model in terms of behavioral health, there are some people who just want to do medical management, stabilize the patient and discharge them. They’re gone, they’re out of our way, versus psychotherapy and really spending some time to help the person get better and manage their condition more effectively. So, helping government think more upstream about how we can be more innovative with programs, whether it’s through Medicaid or other kinds of activities.

We’re also exploring new partnerships with the school districts. A lot of hospitals have partnered with schools on annual physicals before they come to school so that they can play sports. And many of them are working with students in terms of health care careers. But are there other kinds of engagements we can talk about in terms of toxic stress, particularly substance abuse or eating disorders. And then, the final one continues to be the faith-based community, and is there more that we can do with them as we move forward.

Those are some of the new folks that we’re thinking about as we as we prepare to move forward, and we’re hoping, too, that maybe some of the community health needs assessments can help influence and drive some of that work as well.

Any sorts of community resiliency initiatives that your member hospitals in Missouri had adopted following the release of these data? How are your members aiming to address this issue going forward at the local level?

KUHN: I don’t know if this data influenced them, but one of the programs I really admire was at BJC Healthcare over in St. Louis. That initiative they launched a couple of years ago focused on mentoring kids in school, and they really helped the children improve their reading. And so, getting their employees to engage with the public school system in outreach because I think the evidence shows, kind of like ACEs, if there are certain things that are developed early in age, like reading as a skill, versus kind of the trauma issues out there, are there ways that we can have them better prepared, better ready as they get older as they go forward. They’re thinking very differently about different ways of engaging, and that’s certainly one that I’ve admired and I think makes a lot of sense.

What advice can you offer to hospital leaders across the country who are grappling with some of these same issues?

KUHN: I don’t know I have any incredible words of wisdom here, other than the fact that, as I said before, everyone has a story. The key is, do we have the time and the patience to really understand people’s stories, where we can engage them and try to create the programs and services to try and help them do that? I think the mindfulness of health care leaders to recognize that and continue to try to create conditions-specific opportunities for folks to engage in different communities and test different models is where we need to be at this time. Data is going to be key, and it really is a tool to help us target better as we move forward. We can’t be everywhere. We can’t be all things to all people, but the data gives us this unique tool to better target, and a chance for us to really listen and learn and get better at what we do.